To promote the series #asawoman started by @nataliecrawfordmd (from Instagram)
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Throughout medical school, residency, fellowship, even now in private practice… patients have often judged a book by its cover. They’ve thought I was their nurse, volunteer, high school student or college student shadowing, almost everything but the person who will lead their anesthetic care. While this can seem deflating given all the extra work and studies one puts in to become a physician, I’ve changed my mindset re: my patients’ initial thoughts on me.
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First of all, thank goodness they think I’m super young! I have my mom’s genes and beautiful skin to thank!! At this rate, I hope I start to look 30 when I hit 50. When patients ask my age, I happily oblige them with a bold 39. Then I see a look of relief over their faces. I, of course, ask them how old they think I am….and I get the range of: just graduated college to mid-20s. Awesome!! I use it as a bonding moment and icebreaker with my patients. Sometimes with the right patient, I joke with them that it’s my first day… it usually entertains a good laugh. Then, I go into an overly technical schpeel on risks/benefits of anesthesia, expectations, PACU recovery. This typically solidifies to the patient that it’s not my first day on the job. Additionally, many patients tell me in the PACU that they feel better than their prior experience or better than their expectation and are quite grateful for my care.
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There are a lot of men in my anesthesia group. Sometimes, after I introduce myself to the patient, they’re shocked that a woman anesthesiologist would be delivering their care. In this day and age, I’m shocked that a lot of patients still assume that a male physician will oversee their care. When caring for female patients with this mentality, I purposefully address a gentle and vigilant anesthetic plan. With my male patients with this mentality, often times they’re happy to talk about the “happy juice” cocktail they’ll get and some much deserved relaxation knowing that I will carry a watchful eye over their surgery and anesthetic.
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Lastly, since becoming pregnant with my first and currently pregnant with my second… I feel I have a better understanding of the worried/concerned parents who are at the bedside to be with their child about to enter surgery. Oftentimes, the parents think I’m young and want to know where I trained and when I graduated. I offer them this info, and continue speaking to the patient (their child) about their concerns or questions. I make sure the parents know everything that will go on re: anesthetic plan, how the patient will feel in recovery and risks/benefits of anesthesia options. I TAKE MY TIME with the parents and the patient. While my age and gender often work against me (even though it shouldn’t!), I make sure the controllable worries by the parents are addressed. I speak to the parents after the surgery. They go into the recovery room and see their child (older than 13 at our hospital) comfortable and recovering. While I can’t change my appearance (nor would I want to…), I can change perceptions of women physicians. We are every bit as capable of everything our male colleagues can do. In addition, we tackle pregnancy, motherhood, businesses, and everything in between. #asawoman As A Woman, I feel more empowered now than ever before.
I don’t get too frazzled by things in general. It’s important as an anesthesiologist to keep your cool and to keep your wits about you. Well, I just about lost it today when the topic of vaccines came up and someone sent me this video. Granted, I did my due diligence and watched that video. I’m typically open to suggestions and people’s opinions.
First of all, my criticism isn’t about his holistic or chiropractic care. My criticism is about his “expertise” in medicine and vaccines, which he isn’t qualified to opine. The guy in the video has absolutely no understanding of how statistics work. Going to a website to show data where you just show numbers of deaths doesn’t validate your point. Sadly, it’s shocking to me to see that people believe in this hack. I can’t even put it politely because it’s people like him who spread the word that vaccines are harmful and cause more harm than good… and people actually believe him.
I want the best for myself, my family, and my friends. I will continue to be a voice for pro-vaccines. Given all the existing research and statistically significant data, I do believe that vaccines are beneficial in preventing disease.
Key points:
Do your research
Listen to the experts in the field (not quacks who pretend)
Do no harm
Get vaccinated! You’re protecting yourself and others around you!
You have devoted the last decade of your life to medical school, residency, and fellowship. It’s time to get out into the real world for a REAL job. Where do you want to live? What type of practice would you like?
From AMA
Timing is everything. Start early!
I started my fellowship in August. During my elective pediatric hearts rotation, I met a team of physicians who were very encouraging and asked if I had a job yet (this was October). I told them I didn’t have a job yet, but I wanted to stay in California. Maybe it was my lucky day, but one of the lady docs I worked with sat on the application committee for my current job. She encouraged me to apply to their anesthesia group. After going through the proper channels, I got a phone call from the anesthesia group saying they would like to interview me for a position. I had my interview in November and heard back in December that I had a job. Everything happened in such quick succession. When I left residency, I knew I wanted to be in southern California. Thank goodness I matched into a fellowship spot in Southern California! It makes it easier if you know what area/region/state you want to practice in. Keep in mind that some states are more friendly to physicians than others.
What type of practice works for you? Do you want a large academic center with a physician-led team approach to healthcare? Do you want to practice in a private practice setting in a team or solo? There are so many practice models out there — I wish residencies explored/explained more of these options. Fortunately, I knew a solo-practice physician-only model would work best for me.
Keep in mind the number of hours you want to work. What are the opportunities for working more or less? How many vacation weeks will you get? Is there paid-time-off? Will you have a salary or productivity-based income? How many calls/month will you take? Is there a discrepancy between new hires vs. senior partners in access to vacation/salary/calls/etc.? Is there fairness in scheduling? How long will it take to make partner? What’s the buy-in amount? Is there a buy-out when you leave/retire? I didn’t know to ask these questions when I was going through the process of looking for my job. Don’t forget to ask about retirement options and health insurance coverage. Also, ask if it’s possible to work at another hospital or surgery center in the area or if there is a non-compete clause in the contract.
The Interview
Bring your best self to the interview. The people who are interviewing you want to know more about you. Tell them about your hobbies, lifestyle, goals for the group, plans for the future. Engage your interviewer and ask them how long they’ve been with the group. How do they enjoy their time? Keep in mind that they’re interviewing you because you look great on paper. They want a chance to get to know you better. Show them your best self, especially all your hobbies and interests outside of medicine. Keep the conversation casual and inviting.
The Contract
Read over the contract carefully. My group has a one year contract that is revisited yearly and is the same for every member of our 250+ physician group. Before I started, some people recommended a contract attorney specializing in medical contracts to read it over. I didn’t find it necessary in my case as my contract was the same for every physician in my group and the language was very clear to understand. Use your own judgement. If you don’t understand the contract, get some help.
What recommendations did you find helpful in your job search and interview?
I was shocked to see that the NHS could ban surgery for the obese and smokers. That’s socialized medicine. You take a conglomerate group of people (the UK) on a limited budget for healthcare… and basically find the cheapest most cost-effective way to deliver healthcare. But in a way, it’s empowering patients to take responsibility for their own health. Smoking, for sure — I agree 100% that surgery should be banned for this population. Obesity is a bit trickier — there’s genetics and environmental factors at play in this one. I don’t think anyone chooses to be obese. But, people do have the power to change their eating and exercise habits. Despite these efforts, there are some people who are still obese…. and these people should not be faulted.
Why single out the obese and smokers?
From SlideShareFrom SlideShareFrom TobaccoFreeLife.org
Smokers and the obese have elevated surgical risk and mortality, which means more cost to treat and hospitalize and provide ongoing care.
From HealthStats
I think the NHS is on to something here. They’re opening doors to moving the liability and responsibility away from physicians and towards patients. This is a plus. Outsiders may see it as separatism and elitist to only provide care for people who are healthy. But look at the facts and the data…. obesity has a lot of co-morbidities associated. Smoking has a lot of co-morbidities associated as well. Why should physicians be penalized for re-admissions, poor wound healing, longer hospitalizations when the underlying conditions themselves are already challenging enough? In fact, I would urge insurance companies to provide incentives to patients/the insured with discounted rates for good and maintained health and wellness. With all the technologies, medications, and information out there, it’s time patients take responsibility for their own health. I take responsibility for mine — watching my diet, exercising, working on getting enough rest, maintaining activities to keep my mind and body engaged, meditating for rest and relaxation. It’s not easy, but my health is 100% my responsibility. I refuse to pass the buck to my husband, my family, my physician, etc. I do what I can to optimize my health and future — and if that doesn’t work… I call for backup.
Patients need to change their mindset re: health. It is not your spouse’s responsibility to track your meds. It is your responsibility to know your medical conditions and surgical history. The single most important (and thoughtful) thing a patient can do is keep an up-to-date list of medications, past/current medical history, surgical history, and allergies to bring to every doctor’s appointment and surgery. This helps streamline and bring to the forefront your conditions and how these will interplay with your medical and surgical plan and postoperative care. Please do not forget recreational drugs, smoking habit, and drinking habit in this list. It is very important to know all of these things. Also, your emotional history is very important. Depression, anxiety, failure to cope, etc. This all helps tie in your current living situation with stressors and your medical history.
Links for educating yourself in taking responsibility for your health:
Trends are evolving in decreasing intraoperative and postoperative opioid use. Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain. For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks. I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.
Conclusions: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.
Today, I’m #20 on the call schedule after being #2 last night. It wasn’t bad… I left work around 7:30p and never got called back to the hospital. That’s a great #2 night! A couple of days ago, I awoke with a pinched nerve along the left side of my neck and it’s incredibly uncomfortable turning my head and just doing regular tasks (i.e. making the bed). Right now, I wreak of Bengay and I’m partially comforted with some Aleve. Hot compress, you are next! Sometimes, it’s really nice to enjoy a lazy morning with zero agenda other than to catch up on life and maybe even do some self reflection.
A buddy of mine sent me this article and asked me my thoughts….
I gave it a once over and thought, this is interested. A small sample size of various parents from various geographical regions all commenting on their children. Their is italicized because it seems like commenting on what the perfect number of children to have is so personal and completely unique to their experience.
It’s a heavy duty article with a lot of good perspective. I kind of agree with them all. I liked the one with 3 kids best… and the one with no kids the least. Since when did the purpose of procreation become about supporting the older generation? I had a tough one with that. I don’t think people have kids to look after them in old age.
What do u think?
This article came at a perfect time for me. Bear and I just got married; we’re older… and we’re looking to start a family. I just went on an Amazon spending spree for knowledge:
Even as an M.D., I am thirsty for knowledge in an area that I know pretty little about. Sure, I’ve rotated on OB/GYN as a med student — but that was back in 2005. Plus, doing two months of a rotation doesn’t equal a full understanding of mom’s body and baby’s development. It taught me how to safely deliver a baby, but I need to know and understand the building blocks leading up to that. Secondly, I’m an anesthesiologist who places labor epidurals for our pregnant ladies getting ready to welcome their little bundles of joy into the world. I typically meet the moms when they are having contractions and wanting pain control and follow-up with them at delivery. So you can see, there’s a 9 month knowledge gap that I need to fill in.
If you’re a future mom and are interested in an epidural, educate yourself on the pros and cons as well as what you expect to feel and when to ask for an epidural.
Remember, it is dependent on YOU as you are in control of your pain. A pain scale will vary from person to person (i.e. everyone has different pain tolerances). There’s no magical dilation number that tells you when to ask for an epidural. Keep in mind that you will need to hold extremely still when you do ask for an epidural. So please make it easy on your anesthesiologist (and yourself) and ask for an epidural when you are able to be as motionless as a statue — otherwise, it may be too risky to request an epidural if you are in too much pain to stay still.
What does that even mean? My best guess is that it means I went to school for a long time and entered a career where I get to behave professionally and interact with people. Fast forward 18 years after graduating high school and I have a successful career in medicine doing anesthesia. I have met some fantastic people along my journey and I’ve traveled and experienced life to the fullest.
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So why this post?
Because I’m 35 and according to the OB/GYNs…I’m AMA (advanced maternal age). In a nutshell, it means that after the age of 35, there are significant (possibly exponential?) risks of chromosomal abnormalities with my eggs or there could be serious problems with my baby at my age. The older I get, the more I’d like the option of having a family… and that’s whether I meet the right guy or not.
From Wikipedia (James Heilman, MD): The risk of having a Down syndrome pregnancy in relation to a mothers age.
What’s it like to undergo hormone stimulation?
Tues, March 3: I’m currently on day #5 of injections and I still feel normal (i.e. no crazy hormonal emotions or anything; no bloating; no weird experiences, etc.).I don’t have any emotional drama; no crazy hormonal thoughts or outbursts. I actually feel pretty normal. No bloating, no PMS, etc. I don’t know what I’m supposed to feel bc I feel just normal… like a normal day without the injections. Now, the injections –> I’m starting to dread the 7pm hour bc these injections are starting to hurt! I’m a pretty tough cookie… don’t be fooled by the smiling youngish face.
The meds and my mini sharps container
Fri, March 6: I’m bloated. Cravings are starting to kick in, but maybe it’s just stress at work? No crazy emotional stuff.
Sat, March 7: The bloating continues. In fact, my ovaries are pretty sensitive — any big bounces in the car or if I sit down hard is painfully noticeable. The Ganirelix stings a little bit more than the others on injection. No big hikes or active things: no trail running, no running (period!), no elliptical, no jumping. I’m starting my couch potato life and getting stir-crazy! But, I did do a 7 mile flat hike today — I couldn’t help it!
Sun, March 8: The bloating continues. I definitely feel the pull/sensitivity of both my ovaries. Even when I empty my bladder, the pressure/tug release is definitely present. Huge mishap today: I underestimated how much Follistim I had! Today, I was supposed to go up on Menopur, but I didn’t have any extra, so I was told to take my standard 150 dose. Yet, they told me to go up to 300 on Follistim today and I barely had any when I stuck the needle in! I remembered I had an extra vial with just a small amount left and injected that. it was only 150. 3 injections in one night is no fun.
Mon, March 9: Gave myself an additional 150 follistim this morning once the pharmacy opened. 15mm follicles are looking good! My left ovary has a ton! The right ovary is doing alright as well. Just waiting to get the estrogen level up. Same bloated feeling. No physical activity or heavy lifting.
Tues, March 10: Estrogen is finally above 1,000! Apparently after many years of birth control pills, it suppresses estrogen… on track!
Thurs, March 12: All systems go for Friday retrieval. 🙂 My last injection was this morning. I’m incredibly happy to be done with those! The indomethacin makes my head cloudy — not sure I like the feeling.
Fri, March 13: yes it’s Friday the 13th. But I’m not superstitious. Showed up at 6 am and proceeded with paperwork. Estrogen and progesterone levels were fantastic. Went back to the OR around 7am. A little propofol and fentanyl for my MAC case. I requested no versed. Some Toradol in the pacu to help with cramping. Had a fine relaxing day after. Took some tylenol for cramps. They retrieved 13 eggs. 6 mature ones and 5 not quite mature ones. Wonder what we do from here. I’m still super bloated and my doc said no physical activity for 2 weeks.
Tues, March 17: The bloating is getting better. There wasn’t much cramping or pain or spotting after the retrieval. Maybe I am lucky? I only took Tylenol twice since Friday. The bloating was extremely intense Saturday, Sunday, and Monday. I feel that it is better today.
Wed, March 18: I was thinking more about the numbers of eggs retrieved and came upon a couple of different articles and resources. I haven’t chatted with my doc yet.
Sun, Mar 15: Doxycycline 100 bid. Baby aspirin, prenatal vitamins.
Mon, Mar 16: Doxycycline 100 bid. Baby aspirin, prenatal vitamins.
Tues, Mar 17: Doxycycline 100 bid. Baby aspirin, prenatal vitamins.
Wed, Mar 18: Doxycycline 100 bid. Baby aspirin, prenatal vitamins.
Thurs, Mar 19: Could this be my first normal day??? Holy cow!
Fri, Mar 27: They said they got 13 eggs… but they didn’t tell me 6 were mature and 3 were intermediate. When i had my initial consultation… i told her i wanted 2-4 kids possible. If i assume wcs (worst case scenario), which i should in this case… that would mean at best only 1 or 2 kids. I was completely deflated. so i am going to do a second round. it’s not what i want to do, but it’s my best chance. She thinks it’s bc i’ve been on bc pill for so long, so i can’t take those from now until my next go. She’s aiming for July 2015. She saw plenty of follicles (which is good)…. but my hormones had been suppressed so long bc of the bc pill. I’m sad bc i have to do this again…. and it was hard enough the first time.
In this whole process, I met a wonderful man. We are looking at doing embryos for a higher success rate.
Mon, July 13: Prolactin level is 38 on re-draw from fri. 😀 that is normally where I hang out. We decided no repeat MRI (I had been getting them annually for 5 years after surgery to assess growth — I think last was 2010). No growth with drawing prolactin at those times as well as checking for visual field defects annually still. All points to good signs. She’s going to reach out to my endocrinologist and I’m going to get back on bromocriptine (to make my prolactin normal). I wanted to normalize prolactin first before getting on an estrogen stimulating med (that can grow the old prolactinoma). So… I also told her about you and that we’re looking at a possibility of embryos instead of just eggs. She felt very positive about that bc she said I had plenty of follicles and that would ultimately a higher success rate. And she also knows about my prior long use of birth control pills for regulating periods (bc of prolactinoma). All of this points to a good sign that things are normalizing and we have a plan. She said she’d like to see me on bromocriptine for about 3months and would be getting another prolactin draw 6mo after starting that med.
When I was a kid and had to get immunized, my dad used to tell me “don’t be a chicken shit.” And I wasn’t. When I was 4, I vividly remember putting my arm out voluntarily when I had to get a shot. What’s more odd, is that at the tender age of 4, I would watch the needle placement into my arm and not look away. It was single-handedly one of the best lessons my dad ever taught me. Face your fears directly. So, my present-day self is perhaps a bit more squeamish giving my own shots into my abdomen. The injections are given subcutaneously, which means that it goes into the fat layer below the skin but above the muscle.
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Why Am I Doing This?
I wanted to preserve my fertility and not feel so rushed to find “Mr. Right For Me.” To be honest, I never thought I would be taking this journey… let alone by myself. I always envisioned being with the love of my life and starting a family once I achieved my career. But nature and the biological clock don’t stop. That’s life. So I’m making the best of my situation and hoping to preserve my future and share it with someone who will explore and share this journey of life with me.
Because in the end, happiness deserves to be shared.
In the United States, more than 100,000 women of reproductive age receive a diagnosis of cancer each year, and they are at risk for diminished reproductive potential or infertility as a result of treatment. The freezing of oocytes has become a clinically viable option for women who wish to have a child in the future but are facing either an age-related or iatrogenic decrease in the quality and quantity of oocytes.
Clinical Pearls
What is currently the preferred method for cryopreservation of oocytes?
The large size and high water content of oocytes make the formation of ice crystals and subsequent cell injury or death difficult to avoid during the cooling process. Vitrification has replaced the slow-freeze method as the method of choice for cryopreserving oocytes, since it minimizes ice-crystal formation and results in higher rates of cell survival, fertilization, embryo development, and pregnancy. As compared with the slow-freeze method, vitrification involves exposure of oocytes to relatively higher concentrations of cryoprotectants for a shorter duration, followed by ultrarapid cooling either through direct immersion into liquid nitrogen (in so-called open systems) or with the use of small, volume-sealed straws (in closed systems). Once vitrified, the cells can be stored indefinitely in liquid nitrogen.
Is there an association between cryopreservation of oocytes and subsequent congenital abnormalities?
Oocyte cryopreservation by means of slow freezing or vitrification has not been shown to increase the incidence of aneuploidy or congenital abnormalities in children, although long-term studies involving large numbers of births resulting from thawed oocytes are still lacking. Collection of data on long-term outcomes by the Society for Assisted Reproductive Technology is under way.
Morning Report Questions
Q. What factors are central to the likelihood of achieving a live birth using cryopreserved oocytes?
A. In determining the probability of achieving a live birth with the use of cryopreserved oocytes, the two most critical factors are the woman’s age at oocyte collection and the total number of oocytes available. Rates of embryo implantation decline as women age, owing to increased embryo aneuploidy; this risk applies also to cryopreserved oocytes obtained from older women. Whether cryopreservation further damages the oocyte beyond the normal age-related decrease in oocyte quality is unknown. In a prospective study evaluating the efficiency of oocyte vitrification, the proportion of vitrified oocytes that resulted in a live birth was 8.2% (12.1 oocytes per live birth) in women 30 to 36 years of age and 3.3% (29.6 oocytes per live birth) in women 36 to 39 years of age. In a multicenter observational study that assessed predictors of outcome when oocytes were vitrified, the live-birth rate decreased by 7% for every year of increase in the age of the woman. For every additional mature oocyte, the delivery rate increased by 8%.
Q. What are the guidelines of the relevant professional societies concerning oocyte cryopreservation?
A. The American Society for Reproductive Medicine suggests that oocyte vitrification and warming should be recommended to women facing infertility due to chemotherapy or other gonadotoxic therapies. The American Society of Clinical Oncology recommends that “even if women are ambivalent” about having children, they should be referred to a reproductive endocrinologist. However, the guidelines of the American Society for Reproductive Medicine also recommend caution regarding the use of oocyte vitrification to circumvent the effects of age on the reproductive potential of healthy women. These guidelines specifically state that “ . . . there are no data to support the safety, efficacy, ethics, emotional risks and cost-effectiveness of oocyte cryopreservation for this indication.”
Table 1. Reasons to Consider Cryopreservation of Oocytes.
ROUND 2
Cycle day 1- Call doc to schedule a BASE US and blood draw for cycle day 3.
Begin checking for ovulation surge with ovulation predictor kit on cycle day 8.
Call me when the surge is positive.
o Doc will make me a calendar when I surge that maps out the rest of my cycle
6 days post surge you will begin taking Estrace for about 2-3 weeks
After Estrace course you will begin stimulation with Menopur and Follistim again or Menopur and Clomid
What is currently the preferred method for cryopreservation of oocytes?
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